Medical Records Director

About the role

This position is responsible for organizing, planning, and directing the medical records department, assisting the Medical Records/Health Information Consultant, maintaining minutes of meetings, filing, and abstracting information.

Responsibilities

• Follow work schedule and instructions from supervisor
• Aid in organizing and directing the medical records department
• Assist the Medical Records/Health Information Consultant as needed
• Maintain minutes of meetings
• Filing as necessary
• Develop and maintain good working relationships with inter-department personnel
• Record all incidents/accidents
• File resident records according to policies
• Retrieve resident records manually or electronically
• Transcribe and type reports for physicians
• Collect, assemble, check, and file resident charts as required
• Absorb information from records for insurance companies, Medicare, Medicaid, VA, etc.
• Index medical records as directed
• Ensure incomplete records are returned to appropriate departments
• Assist in developing procedures for proper record completion, assembly, coding, signing, and indexing
• Establish procedures to prevent resident records from leaving the medical records room without authorization
• Maintain records of authorized information releases
• Abstract information from records as required
• Batch resident information into the computer and retrieve resident demographic information as needed
• Answer telephone inquiries about medical records
• Prepare written correspondence as necessary
• Retrieve medical records as requested by authorized personnel
• Ensure medical records taken from the department are signed out and signed in upon return
• File active and inactive records according to policies
• Index medical records as directed
• Report known or suspected incidents of fraud to the Administrator
• Attend and participate in mandatory facility in-service training programs
• Assume administrative authority, responsibility, and accountability for assigned duties

Qualifications

• High school diploma or GED
• Minimum typing speed of 45 words per minute
• Working knowledge of medical terminology, anatomy, physiology, legal aspects of health information, coding, indexing, etc. (preferred but not required)
• On-the-job training in medical record and health information system procedures
• Knowledge of medical terminology
• Knowledge of computers, data retrieval, input, and output functions
• Ability to read, write, speak, and understand the English language
• Ability to apply mathematical concepts to practical situations
• Ability to make independent decisions when necessary
• Ability to work harmoniously with others
• Ability to minimize waste of supplies, misuse of equipment, etc.
• Ability to seek out new methods and principles and incorporate them into existing practices
• Ability to follow written and oral instructions
• Personal integrity, flexibility, and the ability to work effectively with others
• General health requirements set forth by the policies of this facility
• Physical demands: move intermittently throughout the workday, able to lift a minimum of 25 pounds to a minimum height of 5 feet and push/pull/carry such weight a minimum distance of 50 feet

Skills

• Medical Terminology
• Computer Skills
• Mathematical Skills
• Decision Making
• Communication Skills
• Teamwork
• Problem Solving
• Flexibility

Benefits

Not specified

Pay

Not specified

Schedule

Not specified

Committee Functions

Perform secretarial duties for committees of the facility as directed.

Personnel Functions

• Report known or suspected incidents of fraud to the Administrator
• Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen saver activates within established facility policy guidelines
• Supervise staff, including taking appropriate disciplinary measures
• Maintain census and report status changes
• Attend and participate in mandatory facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.)
• Attend and participate in workshops, seminars, etc., as approved

Safety and Sanitation

• Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately
• Report equipment malfunctions or breakdowns to your supervisor as soon as possible
• Ensure supplies have been replenished in work areas as necessary
• Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.

Budget and Planning Functions

• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Other duties as assigned

Not specified

Supervisory Requirements

• This position has direct reports

Additional Information

Note: Nothing in this job specification restricts management's right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons. The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position. We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.